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JONATHAN NISSANOFF, MDMedical Director:

Orthopedic Specialist of Southern California

This lecture contains a general discussion of means and methods of billing collections and legal principles applicable in California. This should not be taken as specific legal advice. Practice structure and operational issues have become legally complex due to significant amounts of governmental regulation. We urge each doctor to consult with a competent healthcare attorney on these and other issues affecting the practice of healthcare issues.

Jonathan Nissanoff MD has a financial relationship with :

E.C.U.R.E.

YDM Management Inc.

Orthopedic Specialists of Southern California

Advanced Orthopedic Center

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Physicians need to review all non-contracted EOBs- (at least the surgical ones.)

Learn how to read them

Learn how to appeal them

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First bill out

◦ $1 in staff cost to plug CPT codes in computer◦ 50 cents to mail out each bill◦ Time to input EOBs into billing software

Appeal letter = $5 in staff time

Phone call, return calls, negotiations, etc. = $45

If you are paying 5% for billing, then any amount under $1000 ( 5%=$50) is going to be at their cost and will not generate them any income (IF THEY EVEN ARE ABLE TO COLLECT THE FUNDS!)

The insurance companies know this and therefore will reduce your bills to an amount that your biller or you will not want to pursue through collections

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The DMHC and the California Supreme Court have made it clear that a court action remains an available recourse for providers seeking proper reimbursement for emergency care services rendered to a plan’s enrollee

◦ (See Bell v. Blue Cross of California (2005) 131 Cal.App.4th 211)

Why Litigation?◦ A law suit gets the claim into a decision maker’s

hands

◦ Encourages the insurance carrier to settle

◦ Leads to either settlement or judgment ruling

Litigation Time Estimates◦ Small claims court <$2500 approx 3-6 months

◦ Limited jurisdiction court <$25,000 approx 1 year

◦ Unlimited jurisdiction >$25000 2-3 years

◦ Federal Court >$100,000 2-5 years

Properly defined UCR rates MUST take into account the following:

◦ 1. The providers training, qualification, and length of time in practice;

◦ 2. The nature of the services provided;

◦ 3. The fees usually charged by the provider;

◦ 4. Prevailing provider rates in the general geographic area in which the services were rendered;

◦ 5. Other aspects of the economics of the medical provider’s practice that are relevant; and

◦ 6. Any unusual circumstances in the case.

(28 C.C.R. §1300.71(a)(3)(B))

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Costly – legal fees average $350/hour

Court filing fees = approx $500

Deposition fees= thousands of dollars

Expert fees= thousands of dollars

Court reporter fees= hundreds of dollars

Jury fees= hundreds of dollars

Collusion/anti trust issues when litigating with other providers as a group

ONE COMPANY LITIGATING Company purchases ALL physician, surgery center, hospital, and

other health care provider bills for 50% of what eventually is collected

NO risk to physician

NO cost to physician

All costs incurred by Company

Company is able to do this by combining all accounts from hundreds if not thousands of providers and filing suit under one plaintiff (economies of scale)

NO ANTI TRUST ISSUES.

Car Accidents

Slip and Fall

Bike Accidents

Sports Injuries

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Most likely there is some sort of insurance

Most likely there is a lawyer litigating the case against the liable party’s insurance

The liable party’s insurance will most likely pay a settlement or judgment amount

YOU, as a treating doctor, have a right to get paid for your services- but need to do so before money leaves the attorney’s trust account!

Medicare pays 80% of their fee schedule

Participant = 100% of fee schedule (80% from Medicare and 20% from Patient)

Non-Participating = 115% of fee schedule (80% from Medicare and 35% from Patient)

Opt-Out= UCR from patient (but hospital and ER is 115% of fee schedule by statute from Medicare)

Generally not legal unless you discount the carrier the same amount

All charges must remain constant-write off balances for medicare, medicaid, and WC

Exceptions◦ Prompt payment discount

◦ Hardship discount

◦ Bad debt - legal requirement to bill but NO legal requirement to collect

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Here are just a few of the cases where billing related errors (professional courtesy, insurance only, out-of-network write-offs, and balance billing) ended in very-real legal nightmares:

CA physician gets 5 days in jail and $562,500 fine

Insurance carrier sues practice to repay collected revenue deemed balancing billing ($4.3 million)

Pulmonology practice pays $10K in fines and $2.5 million to repay collected funds

It's no longer as simple as sending out an invoice and getting paid for your services, or providing free care to your employees. Unless you really understand how to correctly maneuver through the legal pitfalls of billing for your services, you could end up like the physicians above.

Phone calls

Discussions with other healthcare providers

Coordination of care

Following coagulation numbers for a patient on anticoagulants

After-hours and out-of-office treatment

Emergency care during office hours

Handling specimens

Tobacco cessation

Reviewing electronic data

Using modifiers

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99441 - Phone by Physician 5 to 10 minutes of medical discussion

99442 - Phone by Physician 11 to 20 minutes of medical discussion

99443 - Phone by Physician 21 to 31 minutes of medical discussion

99367 - Medical team conference with interdisciplinary team of healthcare professionals, patient and/or family not present, 30 minutes or more, participation by physician

99368 - Medical team conference with interdisciplinary team of healthcare professionals, patient and/or family not present 30 minutes or more, participation by non-physician qualified healthcare professional

99444 - Online E&M by Physician of medical discussion

98969 - Online service by other Healthcare Provider

98966 - Healthcare Provider phone call 5 to 10 minutes of medical discussion

98967 - Healthcare Provider phone call 11 to 20 minutes of medical discussion

98968 - Healthcare Provider phone call 21 to 30 minutes of medical discussion

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CPT code 99363 is to be used after the initial 90 days of outpatient warfarin therapy. The code is intended to reimburse the physician work involved in adjusting warfarin levels based on a review of a patient’s international normalized ratio (INR) measurements

CPT code 99364 is very similar, but is to be used for subsequent 90-day periods of management and only requires three INR measurements during these time periods

99056 - Services typically provided in the office, provided out of the office at request of patient, in addition to basic service

99053 - Services provided between 10:00 PM and 8:00 AM at 24-hour facility, in addition to basic service

99050 - Services provided in the office during regularly scheduled evening, weekend, or holiday office hours, in addition to basic service

99051 - Services provided in the office at times other than regularly scheduled office hours, or days when the office is normally closed (e.g. holidays, Saturday or Sunday), in addition to basic service)

99060 - Services provided on an emergency basis, out of the office, which disrupts other scheduled office services, in addition to basic service

99058 - Services provided on an emergency basis in the office, which disrupts other scheduled office services, in addition to basic service

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Code 36415 may be reported for collection of venous blood by venipuncture

Code 36416 may be used for collection of capillary blood specimen (e.g., a finger or heel stick)

You can report CPT code 99000, “Handling and/or conveyance of specimen for transfer from the physician's office to a laboratory,” to represent the work and costs you incur preparing a specimen for transport (e.g., centrifuging, separating serum and labeling tubes)”

99406 and 99407

These codes should be selected based on the amount of time devoted to the counseling

◦ Use 99406 for 3 to 10 minutes

◦ Use 99407 for more than 10 minutes.

99080 - report generated and/or form filled out OMFS 99080= $37.98

99354 - Prolonged physician service in the office or other outpatient setting requiring direct (face-to-face) patient contact beyond the usual service; first hour (To be reported along with CPT codes 90809, 90815, 99201-99215, 99241-99245, 99324-99337 and 99341-99350).

OMFS Regulations 99354 $171.19

99355 - Prolonged physician service in the office or other outpatient setting requiring direct (face-to-face) patient contact beyond the usual service; each additional 30 minutes (To be reported along with CPT code 99354).

OMFS FEE SCHEDULE 99355 $90.10

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99356 - Prolonged physician service in the inpatient setting, requiring unit/floor time beyond the usual service; first hour

Omfs= $197.84

99357 - Prolonged physician service in the inpatient setting, requiring unit/floor time beyond the usual service; each additional 30 minutes .

Omfs= $98.52

99358 - Prolonged evaluation and management service before and/or after direct (face-to-face) patient care (e.g., review of extensive records and tests, communication with other professionals and/or the patient/family); first hour.

Omfs= $36.34

99359 - Prolonged evaluation and management service before and/or after direct (face-to-face) patient care (e.g., review of extensive records and tests, communication with other professionals and/or the patient/family); each additional 30 minutes.

-93 - Interpreter needed◦ add 10% to bill

99070 – supplies

NDC numbers for medication and injectibles

99071 - educational materials

99082 - escort of a patient

99090 - analysis of clinincal data stored in computers (e.g., EKG, blood work)

Always bill closed treatment of fractures with global service data

Better than the patient following up and colleting follow up payments

You still collect copays per follow up visit

If lost to follow up, you still get paid

This is in addition to the decision making E&M code

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prior year 1 year 2 year 3

INCOME in $100,000